PATIENT INFORMATION Mr.Mrs.Miss Last Name First Name Middle Name Marital status SingleMarriedDivorcedSeperatedWidow Is this your legal name? YesNo If not, what is your legal name? Pharmacy: Birth Date: Age: Sex: MaleFemale Street Address: Social Security no: Home phone no: P.O. box: City: State: ZIP Code: Occupation: Employer Address: Employer phone no: Dr. Insurance Plan Hospital Chose clinic because/Referred to clinic by: FamilyFriendClose to home/workYellow PagesOther Names of family members seen here: INSURANCE INFORMATION Person responsible for bill: Birth date: Address (if different): Home phone no.: Is this person a patient here? YesNo Occupation Employer Employer phone no: Employer address: Is this patient covered by insurance? YesNo Please indicate primary insurance MedicareBCBSMeridian MedicaidCofinityPriority Health (PPO & HMO)AetnaRail Road MedicareAARPASR HealthOther Subscriber’s name: Subscriber’s S.S. no: Birth date: Group no: Policy no.: Co-payment: Patient’s relationship to subscriber: SelfSpouseChildOther Name of secondary insurance (if applicable): Subscriber’s name: Group no: Policy no: Patient’s relationship to subscriber: SelfSpouseChildOther IN CASE OF EMERGENCY Name of local friend or relative: Relationship to patient: Home phone no: Work phone no: The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the: physician. I understand that I am financially responsible for any balance. I also authorize my insurance company to release any information required to process my claims.